When a California evaluator or treating provider judges that letting an injured worker see or copy a mental health record is likely to cause significant adverse medical consequences, this declaration under Health and Safety Code 123115(b) and 8 CCR 36.5 is attached to the record. The employee's copy then goes to a physician or provider the employee designates.
The licensed provider completes and signs the declaration under penalty of perjury, giving license type and number, the medical basis for the conclusion and how the employee's request was handled.
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Declaration Regarding Protection of Mental Health Record
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When, in the provider's professional judgment under Health and Safety Code 123115(b), the employee seeing or copying the record will or is likely to result in a substantial risk of significant adverse or detrimental medical consequences. The provider describes the medical basis on QME Form 121 and signs under penalty of perjury.
A licensed physician under Labor Code 3209.3, or a health care provider under Health and Safety Code 123105, whom the employee designates. The form records that provider's name, contact details and license number, the designation date, and the date and manner of service.
Health and Safety Code section 123115(b), on a patient's access to mental health records, and section 36.5 of Title 8 of the California Code of Regulations, on service of medical-legal reports involving such records. The current version is Rev. February 2009.